Mastering the Art of Anterior Capsulotomy

“The CAPSULaser provides a circular, accurately sized and centered capsulotomy, better in all respects compared to a manual continuous curvilinear capsulorhexis CCC).” –Dr. Richard Packard

Cataract surgery has truly come of age. Now more than ever, we are witnessing an era of remarkable postoperative patient outcomes. And at the heart of the various factors for favorable patient outcomes, lies a successful anterior capsulotomy. Techniques for capsulotomy have progressed from a crude tear to the current standard of continuous curvilinear capsulorhexis (CCC). 

In 2008, a new automated capsulotomy procedure was performed using the femtosecond laser. And for the very first time, surgeons were able to create anterior capsulotomies of accurate size, roundness and centration. A capsulotomy of accurate size, shape and position helps ensure 360-degree overlap of the intraocular lens (IOL) by the capsulotomy. Furthermore, this reduces the risk for posterior capsule opacification and improves IOL centration and effective lens position. This is particularly important when multifocal and toric IOLs are implanted. 

However, femtosecond laser-assisted cataract surgery has associated caveats; that is, it requires a considerable investment in capital and operating and maintenance costs. The following study assessed the efficacy and safety of a capsulotomy technique performed using the CAPSULaser selective capsulotomy laser (EXCEL-LENS, Inc., California, USA).

Dr. Richard Packard and collaborators from the GEMINI Eye Clinic, Zlin, Czech Republic, compared the efficacy and safety of anterior capsulotomy creation with a new selective laser device (CAPSULaser) with those of manual capsulotomies. Their findings were published in a recent article in the Journal of Cataract and Refractive Surgery.* 

In this prospective case series, the authors included patients with clinically documented diagnosis of grade I to IV cataract according to the Lens Opacities Classification System III, clear corneal media with no corneal disease or pathology that might interfere with passage of the laser light, aged 40 to 79 years, and an endothelial cell count of more than 2000 cells/mm. To be included, patients must have read, understood and signed the informed consent and agreed to be randomized to either treatment group. Standard exclusion criteria were used, and included previous eye surgery, ocular comorbidities and poorly dilating pupils. 

The study protocol stipulated four investigational visits to ensure that the patients fulfilled the eligibility criteria. The patients were subsequently grouped in cohorts, stratified by age and cataract grade, and then randomized to either have laser capsulotomy or manual CCC.

The authors stained the anterior capsules with microfiltered trypan blue, and intraoperative video analysis with the use of an intraocular ruler, and postoperative examinations were used to assess safety and efficacy (accuracy of capsulotomy size, circularity, centration). Dr. Packard and colleagues found no intraoperative complications in either the laser group or the manual group, and all capsulotomies in the laser group were free floating with no tags or tears.

Following analysis of the study results, the authors concluded that selective laser capsulotomy using a new proprietary trypan blue formulation was safe and effective in cataract surgery. Furthermore, the sizing, circularity and centration of the laser capsulotomy were more accurate than those of the manual CCC, resulting in consistent 360-degree IOL coverage. 

Dr. Packard highlighted the major advantages of capsulotomy using CAPSULaser as compared to standard methods. “It provides a circular, accurately sized and centered capsulotomy, better in all respects compared to a manual CCC,” he said. “It is also stronger than both a manual CCC and FLACS capsulotomy. It is simple to perform, and the latest version of the settings can create a capsulotomy in under half a second.”

Dr. Packard provided insights into the most important innovations that have changed the landscape of anterior capsulotomy over the last two decades. “Automated capsulotomy has been brought to the forefront by, initially, the femtosecond laser in FLACS,” he shared. “This has been followed by Zepto with precision pulse capsulotomy. Although the reports of tear out with this have been worrying, it is now available in many countries. CAPSULaser with selective laser capsulotomy achieved a CE mark last year and is currently being evaluated by a number of key opinion leaders (KOLs) across Europe.” 

In addition, he explained that what all of these devices are trying to do is to achieve a well-centered, accurately sized and circular anterior capsulotomy. “This is important to minimize posterior capsular opacification and to assist in the positioning of premium IOLs where this is most important for best visual outcomes,” he said.

Finally, Dr. Packard envisioned the next frontiers in anterior capsulotomy in the coming decades. “The use of the accurately sized, centered and circular anterior capsulotomy to hold the IOL rather than using the oval capsular bag for centration has already been recognized by some lens manufacturers. I believe this trend will continue as these automated devices become more widely used,” he speculated. In addition, he noted that: “IOL companies so far have explored the possibility of using the accurately sized and centered capsulotomy to center and fixate the IOL. This should improve effective lens position prediction and assist in the performance of multifocal IOLs centered on the visual axis.”